In July 1962, a group from WRAIR was sent to
Southeast Asia to evaluate the existing resources
for medical research and to develop plans for
coordination and expansion. They surveyed the
laboratories then operating in East and Southeast
Asia: the Air Force's Fifth Epidemiological Flight
at Yamata, Japan, with one air-transportable
trailer-type bacteriology laboratory, the 406th
Medical General Laboratory at Camp Zama, Japan,
the NAMRU-2 (U.S. Naval Medical Research Unit
No. 2) in Taipei, Taiwan, the U.S. Army Medical
Research Unit in Kuala Lumpur, Malaysia, and
the US Army Medical Component of the SEATO (Southeast
Asia Treaty Organization) Medical Research Laboratory
in Thailand,

At the completion of their survey, the study
group recommended expansion of the existing medical
research program to include studies of US troops
and of local national troops and civilian populations,
allocation of additional personnel and funds,
and establishment in Saigon of a WRAIR medical
research unit, similar to those in Bangkok and
Kuala Lumpur, because a theater laboratory would
not be able to deal with all the subjects to
be covered in the expanded program.

In November 1963, as a result of the survey
group's recommendations, Lieutenant Colonel (later
Colonel) Paul E. Teschan, MC, was sent to Vietnam
with a team of seven officers and 12 enlisted
men. They quickly established liaison with United
States and Vietnamese military medical staffs
and installations, with the Public Health Division
of USOM (US Operations Mission), AID, and, through
them, with the Minister of Health, members of
the Pasteur Institute, the medical school faculties,
medical missionaries, and representatives of
private US charitable and medical foundations.
They thus had access to all populations- Vietnamese
and American, military and civilian- that was
required to detect problems and settings in which
productive investigation could be done and to
deploy and support qualified investigators.

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Studies of the Medical Research Team

Initially the team studied infectious disease, combat surgery, and military
psychiatry, and evaluated new medical materiel. Their first effort was
a serologic survey among US, military advisers in the Delta region for
evidence of viral hepatitis, leptospirosis, and dengue-related viruses.

Cholera

Cholera, absent from Vietnam for 10 years, spread from Cambodia into
Saigon-Cho Lon and some provinces. Several thousand cases appeared within
about 2 months, and the clinics and hospitals were soon overwhelmed. The
disease was found among the destitute and frequently in immunized persons,
Cholera rarely appeared in more than one member of a family and generally
ran a self-limited course, perhaps somewhat shortened by antibiotics. No
Americans were affected.

Dr. Richard Finkelstein, from WRAIR, and Dr.
Howard Noyes, from the SEATO laboratory in Bangkok,
went to Saigon to work in the Pasteur Institute.
Captain Robert A. Phillips, MC, USN, and the
staff of NAMRU-2 arrived from Taipei, instituted
their mass treatment system of replacement of
massive fluid and electrolyte losses, quickly
taught it to the Vietnamese, and soon virtually
eliminated further deaths from cholera.

Plague

Plague caused concern as a potential threat to U.S. troops. Darkened
streets were alive with rats, and the rats were alive with fleas. In late
1962, during a plague epidemic in Saigon, Colonel (later Brigadier General)
William D. Tigertt, MC, and Lieutenant Colonel Kevin G. Barry, MC, had
established a small research unit with personnel from the 7th Medical Laboratory,
whose efforts were directed, primarily toward plague surveillance and diagnosis.
Later, the liaison already developed during the cholera epidemic led to
the joint study of plague by the Ministry of Health, the Pasteur Institute,
and the WRAIR team. Colonel Teschan was appointed by the Minister of Health
to the reactivated Commission for Pathologic Researches in Vietnam. Such
common enterprise was later extended to studies of hemorrhagic dengue which
produced hemorrhagic fever in Vietnamese children and also affected U.S.
troops.

During its second year, under the direction of Lieutenant Colonel Stefano
Vivona, MC, the team developed a close relationship with the Pasteur Institute
in Saigon; through this collaborative effort, the only plague research
laboratory in Southeast Asia was constructed and oper-

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ated. From this laboratory, the extent and severity of plague in Vietnam
were documented; for example, whereas only eight cases were reported from
a single province in 1961, by 1966 human plague was shown to be present
in every province in I, II, and III Corps areas, and in one province in
IV Corps area, with 4,500 cases occurring in 1965 alone. Studies of rodent
reservoirs and flea vectors of plague revealed new endemic foci, and during
a pilot program for rodent and vector control in the Minh Mang district
of Cho Lon, rat fleas were found to be resistant to DDT. These data, in
addition to laboratory studies of the insecticides dieldrin and Diazinon,
provided the Ministry of Health with information essential for reducing
the vectors and controlling the disease.

The common house shrew was shown for the first time to be a reservoir
of plague; an asymptomatic carrier state of virulent plague bacilli in
the throats of healthy people was demonstrated for the first time in Vietnam;
rat and flea survey programs and insecticide evaluation programs were expanded;
and a program was initiated for production and evaluation of a lyophilized,
attenuated living plague vaccine.

Malaria

During its third year, 1965-66, under the direction
of Lieutenant Colonel (later Colonel) Robert
J. T. Joy, MC, the medical research team expanded
its mission to include specific research studies
by individual team members, support of other
research studies by outside investigators, and
collection of medical information or health data
for WRAIR, which would serve as a guide for research
in the laboratories of the USAMRDC (US Army Medical
Research and Development Command). Specific areas
of interest included malaria, plague, gastrointestinal
disease, fevers of undetermined origin, combat
psychiatry, environmental stress, and other causes
of morbidity and mortality in US soldiers.

The data collected warned the team of the possibility
of a rise in the number of cases of chloroquine-resistant
falciparum malaria and they devoted much of their
effort to this disease. Among their contributions
were the discovery of asymptomatic malaria, with
its potential for importation to the continental
United States; documentation of failures of malaria
discipline and personal protective measures,
which provided information needed for control;
introduction of new therapeutic drugs (Fanasil
and pyrimethamine) and other regimens for the
treatment of malaria; and provision of consultative
advice to the various command surgeons. A major
contribution to the control of malaria in Vietnam
was the introduction of DDS (diaminodiphenylsulfone).
The efficacy of this drug as a prophylactic agent
was confirmed in volunteers in the United States,
and in 1966, a field test in Vietnam proved its
value in

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combat troops. Subsequently, it was routinely used by military personnel
in Vietnam for prophylaxis against falciparum malaria.

The team recommended that a central rehabilitation hospital for malaria
patients be established and used simultaneously as a center for studying
the disease and the evaluation of new therapeutic agents. This hospital
was approved by The Surgeon General and became the 6th Convalescent Center
at Cam Ranh Bay. A formal link with the Navy preventive medicine unit in
Da Nang provided for the collection of specimens by the Navy unit, with
laboratory support from the team, and for the exchange of information and
research data. The 61st Medical Detachment of the 20th Preventive Medicine
Unit (entomology) was established and worked with the team in the laboratory.

In the fall of 1966, the team in essence drafted a USARV regulation
on malaria control guided by letters and comments from Colonel Tigertt;
a medical research team for malaria survey for USARV was established; and
Captain Anthony T. C. Bourke, MC, was appointed the USARV consultant in
malaria.

Stress

Studies done by the medical research team of neuroendocrine stress caused
by combat, in helicopter crewmen and Special Forces "A" Detachment
members, contributed significantly to the understanding of the pathophysiology,
of stress in, the soldier. Studies of heat stress incurred by crews of
the Mohawk (OV-1) aircraft led to changes in clothing and to ventilation
of the cockpit, measures which materially improved crew comfort and efficiency.
Collaborative studies with the Department of Neuropsychiatry of the ARVN
Cong Hoa Hospital led to a better understanding of the stresses of combat
affecting both American and Vietnamese soldiers.

Fever of Undetermined Origin

A major collaborative study done by the team with the 93d Evacuation
Hospital and the SEATO laboratory in Bangkok resulted in determining the
specific etiology of FUO in 60 percent of patients studied. Of the cases
diagnosed, 50 percent were due to dengue, with Chikungunya, scrub typhus,
and malaria accounting for most of the remainder. These laboratory results,
carefully correlated with clinical findings, enabled clinicians to suspect
these diseases, in the absence of classical findings, early in the course
of hospitalization.

Renal Failure

In February 1966, Colonel Barry arrived at the 3d Field Hospital in
Saigon to institute clinical research studies in patients with malaria,

131

including studies of body water, extracellular fluid, blood volume,
and renal function. Because the only facilities for performing hemodialysis
were in Japan and the Philippines, delays in evacuation and treatment of
patients with acute renal failure often resulted in increased morbidity
and mortality. Colonel Barry, recognizing the need for in-country treatment
of this complication, established the first renal unit in Vietnam at the
3d Field Hospital.

Special Projects

The Field Epidemiologic Survey Team

The war in Vietnam pointed up deficiencies in the knowledge of certain
important tropical diseases and, more significantly, the deficiencies in
the ability to predict noneffectiveness and in the application of preventive
techniques. It also provided the opportunity for a unique and valuable
experiment in medical support of military operations in a hostile environment.

The FEST (Field Epidentiologic Survey Team) was organized in May 1966
by Lieutenant Colonel Llewellyn J. Legters, MC, preventive medicine officer
of the USA John F. Kennedy Center for Special Warfare at Fort Bragg, N.C.,
who recognized that a research group operating in the remote areas where
U.S. military forces were being committed could study the epidemiology
of tropical diseases in the environment where most of them were transmitted.

The FEST, composed of Special Forces officers and enlisted technicians
stationed at Fort Bragg, was trained at Fort Bragg and at WRAIR in specific
laboratory and field epidemiological, skills suitable for studying diseases
of special interest to the Army Medical Department and in providing medical
support, preventive, and curative, to ground troops in Vietnam. Training
was oriented primarily to specified scientific areas of interest such as
the entomological aspects of tropical sprue, febrile illness, schistosomiasis,
filariasis, dengue, and malaria.

After the training period, FEST was formally constituted as an element,
of WRAIR, deployed to Vietnam on 26 September 1966, and became part of
the medical research team in Saigon for administration and logistics, but
was attached to Headquarters, 5th Special Forces Group.

The studies of this team which continued through 1968, diminishing as
the war became conventionalized, generated valuable scientific information
about malaria, plague, schistosomiasis, filariasis, tropical sprue, and
other ailments.

Dermatological Research

The character of warfare in Vietnam also created unique opportunities
for research on cutaneous diseases of military importance. At the, height
of the rainy season, the rates of disabling skin disease among

132

infantrymen were extremely high, reaching 50 percent in some rifle companies.
Surgeons at the infantry battalion level were often overwhelmed by the
number of soldiers displaying skin lesions of uncertain etiology which
were slow to heal despite vigorous topical and systemic antibiotic therapy.
Combat commanders and physicians alike became extremely receptive to scientific
investigations of the common skin diseases that had defied the most heroic
efforts at prevention and control.

The US Army Medical Research and Development
Command sent a special field epidemiological
research team from WRAIR to the Mekong Delta
in 1968. The team had trained in simulated tropical
combat environment at camps in the southern United
States and in the Florida Everglades under the
supervision of Dr. Harvey Blank of the University
of Miami (Fla.) School of Medicine. Mr. David
Taplin, also a member of the University of Miami
faculty, conducted workshops in applied microbiology
and subsequently accompanied the team to Vietnam
to help establish a base laboratory.

The reception accorded the team assured them
of the support so necessary for productive research
under wartime conditions. The commanding general
of the 9th Infantry Division, Major General (later
Lieutenant General) Julian J. Ewell, pledged
the full cooperation of his officers and men.
The requirement for a laboratory in the Delta
was more than met when the USARV surgeon, General
Neel, made available a completely equipped MUST
unit that provided an ideal setting for microbiological
studies, with negligible risks of contamination
from mud, dust, and insect life. Colonel William
A. Akers, MC, Chief, Dermatology Research Unit,
Letterman Army Institute of Research, promised
cooperation and provided personal liaison at
theater and division levels in Vietnam. Most
important of all was the complete acceptance
of the team by the officers and men of combat
units who displayed a cheerful willingness to
be examined, despite the incursions on their
limited free time.

Under the leadership of Captain (later Major) Alfred M. Allen, MC, the
team conducted intensive research among combat, forces, support troops,
and neighboring Vietnamese populations in the Delta. They examined, American
and Vietnamese infantrymen at forward company and battalion areas in active
fire zones and accompanied infantry units on patrol to evaluate proposed
methods of skin disease prevention. Use of portable field laboratories
and special culture rnedia permitted isolation of pathogens that had eluded
detection by standard methods. In less than 6 months, Captain Allen's team
had precisely identified the populations most,, likely to develop common
disabling skin disease, isolated the offending pathogens, measured the
effects of exposure, and initiated effective new methods of prevention
and treatment.

133

The chief causes of cutaneous disability in American combat forces were
inflammatory ringworm, ecthymatous pyoderma, and tropical immersion foot.
Disease rates correlated with the degree of exposure to such things as
insect bites and prolonged contact with wet clothing. Prickly heat, acne
vulgaris, and tinea versicolor, while common, as a general rule were not
disabling, nor was cystic (tropical) acne, which can be very disabling,
a significant cause of manpower loss.

Elastase-producing fungi were found to be the
major cause of inflammatory ringworm in the American
combat forces. The usual athlete's foot type
was surprisingly rare, being replaced by intensely
inflamed, serum-oozing lesions on the dorsa of
the feet, the ankles, and groin, often forming
multiple small abscesses in hair follicles. The
clinical features and the microbiological characteristics
of the disease indicated that the infections
were transmitted by a source in Vietnam rather
than by irritation of old, latent infections,
as previously believed. A search for sources
of infection revealed that 25 percent of the
wild rats tested were infected with organisms
which were morphologically indistinguishable
from those recovered from American soldiers.

In contrast to those found in infantrymen, the infections among support
troops strongly resembled the type found among troops in training at southern
United States military bases during the summer.

Penicillin treatment significantly reduced healing time of ecthymatous
pyodermas in American soldiers despite a prevalence of penicillin-resistant,
staphylococci. Erythromycin was also effective in a small number of cases.
Tetracycline was avoided because of the high proportion of resistant streptococci
recovered from the pyodermas.

The clinical and pathological features of tropical immersion foot were
consistent with low-grade cold injury. Soldiers who had contracted the
condition following prolonged immersion displayed increased susceptibility
to repeat injury even after complete healing had occurred. Skin biopsies
showed chronic inflammation and dilatation of vascular channels.

Skin infections in Vietnamese adults were strikingly different from
those among Americans, even in military populations with identical exposure.
Trichophyton mentagrophytes infections and streptococcal pyoderma
were rare; ringworm, although fairly common, was nearly always caused by
an atypical variant of Trichophyton rubrum which produced a chronic,
scaly, dry rash generally confined to the waist. Vietnamese children, on
the other hand, were similar to American combat troops in their frequent
experience with streptococcal pyoderma and ringworm.

After Captain Allen's departure from Vietnam, dermatological research
was continued by Captain Joseph Thompson, MC, Captain Joseph M. Ballo,
MC, and Lieutenant Colonel Robert. T. Cutting, MC. The results of two field
trials to determine the efficacy of griseofulvin in the

134

prevention of ringworm, infection showed that it was significantly protective,
provided the recommended dosage schedule was strictly observed.

The field dermatology research program in Vietnam
was rewarding in the relatively brief span of
its existence. Early application of the measures
recommended on the basis of the team's findings
dramatically lowered disability rates wherever
they were put into effect. Research priorities
were realigned to be more directly aimed at prevention
of those diseases having the greatest impact
on combat manpower. Laboratories in the United
States focused their attention on the newly found
clues to pathogenesis of the common disabling
skin infections. Representative isolates of pathogenic
strains of fungi and bacteria recovered in Vietnam
were collected for future study. The influence
of the research findings even extended to the
development of new items of tropical military
footwear. As a direct result of, the dedicated
efforts of this team, and because of military-civilian
cooperation, development of effective methods
to prevent the devastating effects of skin diseases
came, for the first time, within reach.

Photographic Coverage of Army Medical Activities

During the latter part of 1965 it became evident that photographic coverage
of Army medical activities in Vietnam was unsatisfactory. Since the Medical
Audiovisual Department, WRAIR, was capable of providing highly professional
still and motion picture support of the WRAIR's diverse research activities,
it was decided to field a photography team to be attached to the WRAIR
research team but to be equally responsive to direction from the USARV
surgeon.

Two weeks after the decision was made, four civilian volunteers, all
from WRAIR, began a comprehensive coverage of surgery, helicopter evacuation,
combat "medics" in action, field hospital operations, and other
medical activities wherever and whenever they saw them. They formed a highly
mobile and aggressive team, not only responding to requests and direction
from the medical command, but also seeking out on their own initiative
areas and activities requiring photographic coverage.

The Surgeon General, realizing that the team approach was the most efficient
means of acquiring accurate and timely pictorial records of the Army's
medical effort in Vietnam, directed that additional personnel and funds
be provided to establish a permanent team of military medical photographers.
This team, consisting of one officer, one noncommissioned officer, and
three enlisted men, became operational in December 1967. Adhering to the
pattern already established, the new group continued to work closely with
the USARV medical and surgical consultants, following the action to the
areas of greatest activity. Thus began the collection of thousands of color
slides and hundreds of thousands of feet of

135

motion picture film which later became the basis for film libraries,
not only in the United States (such as these at WRAIR and at the Medical
Field Service School at Fort Sam Houston), but also in Europe, Hawaii,
and Asia. At least three major film productions resulted from the footage
obtained, one on helicopter evacuation, another on MUST, and a third, the
award-winning "Army Medicine in Vietnam."

Surgical Research

In its fourth year, the team concentrated on surgical research and on
testing the FEST concept. The research was done by a group which was attached
to the team in April 1966, initially at the 93d Evacuation Hospital, later
at the 3d Surgical Hospital, and finally at the 24th Evacuation Hospital.
The group demonstrated that, studies of the type conducted in "shock
units" in the United States can be carried out with satisfactory results
on combat casualties in the field. Later studies conducted by the research
group contributed to the knowledge of many other subjects.

Recognition of the seriousness of pulmonary insufficiency in shock,
particularly in patients with non thoracic injuries, led to extensive research
in the management of this complication. Plans were made for the development
and testing of new respiratory assistance devices.

Further progress was made in the development and use of plastic polymers
as tissue adhesives in controlling bleeding and repairing internal organs.
Spray guns containing the adhesive were provided the surgical research
team for use in treating casualties in Vietnam.

New methods for fixation of fractures of the jaw were studied, as was
a new technique using a silicone plastic placed directly into oral wounds
to restore temporary oral integrity until reconstructive surgery could
be performed.

Other innovations under study by the research group were the use of
electrical anesthesia, laser irradiation, synthetic blood vessels, plasma
expanders and new additives in the preservation of whole blood. Sulfamylon
ointment for control of infection in burns, and various methods for suppression
of an immune response of the body to homografts, and transplants.